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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
RECORD ADJUSTMENT
JOINTLY HELD OR TRUST ASSETS
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BUREAU OF INDIVIDUAL TA~~ ~0
INHERITANCE TAX DIVISIONDCr, !-,I"':- :
PO BOX Z80601 - ,-
HARRISBURG PA 171Z8-0601
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REV-1604 EX AFP (03-05)
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DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
SSN/DC
ACN
10-20-2006
DALUISIO
07-04-2004
21 05-1080
CUMBERLAND
194-10-6856
04144422
Allount Rellitted
ANNA
M
PA 17055-5685
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE
--+ RETAIN LOWER PORTION FOR YOUR RECORDS
+-
...-----------------------------------------------------------------------------------------------------------------------------------------------------------------
REV-1604 EX AFP (03-05)
__ INHERITANCE TAX RECORD ADJUSTMENT JOINTLY HELD OR TRUST ASSETS --
DATE 10-20-2006
ESTATE OF DALUISIO
ANNA
M DATE OF DEATH 07-04-2004
COUNTY
CUMBERLAND
FILE NO. 21 05-1080
ADJUSTMENT BASED ON:
S.S/D.C. NO. 194-10-6856
ADMINISTRATIVE CORRECTION
JOINT OR TRUST ASSET INFORMATION
ACN
04144422
FINANCIAL INSTITUTION: PSECU
ACCOUNT NO. 0194106856-1
TYPE OF ACCOUNT: (X) SAVINGS () CHECKING () TRUST () TIME CERTIFICATE
DATE ESTABLISHED 03-24-1997
Account Balance
Percent Taxable X
Amount Subject to Tax
Debts and Deductions
Taxable Amount
Tax Rate X
Tax Due
.00
0.500
.00
.00
.00
.45
.00
NOTE: TO INSURE PROPER CREDIT TO YOUR
ACCOUNT, SUBMIT THE UPPER PORTION
OF THIS NOTICE WITH YOUR TAX
PAYMENT TO THE REGISTER OF WILLS
AT THE ADDRESS SHOWN ABOVE.
MAKE CHECK OR MONEY ORDER PAYABLE
TO: "REGISTER OF WILLS, AGENT."
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR),
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
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